JSAFOG
10.5005/jp-journals-10006-1479
Forgotten Transvaginal Cervical Cerclage Stitch in First Pregnancy Benefits reaped till the Second Pregnancy
CASE REPORT
Forgotten Transvaginal Cervical Cerclage Stitch in First
Pregnancy Benefits reaped till the Second Pregnancy
1
Aniket Kakade, 2Yashwant Kulkarni, 3Anmol Mehra
ABSTRACT
The cervical stitch is universally removed at 37 completed weeks
or earlier if the patient goes in labor. The patient described was
a rare incidence where the cervical stitch in the first pregnancy
was forgotten and it was diagnosed in the second pregnancy.
Since the patient did have a short cervical length in second
pregnancy, the stitch was left in situ and was removed at term.
A rare case is presented here where the cervical stitch in the
first pregnancy benefited the second pregnancy.
Keywords: Cervical cerclage, Removal of cervical stitch,
Transvaginal cerclage.
How to cite this article: Kakade A, Kulkarni Y, Mehra A. For-
gotten Transvaginal Cervical Cerclage Stitch in First Pregnancy
Benefits reaped till the Second Pregnancy. J South Asian Feder
Obst Gynae 2017;9(2):141-142.
Source of support: Nil
Conflict of interest: None
Date of received: 10 December 2016
Date of acceptance: 21 January 2017
Date of publication: March 2017
CASE REPORT
A 26-year-old gravida 2, para 1, living 1 with 24 weeks of
pregnancy presented to the antenatal clinic for examina-
tion. The first pregnancy was a full-term elective cesarean
section done for severe oligohydramnios, female baby
2.5 kg, with no complications. There was history of cervi-
cal cerclage done in the first pregnancy for short cervix
and no other details were available.
On routine examination, her pulse was 75 beats/
minute, blood pressure was normal, and she had mild
pallor. On per abdomen examination, the uterus was
24 weeks size, external ballotement present, fetal heart
sounds were heard, and a healthy scar of previous cesar-
ean section was seen. On per speculum examination, an
1,2
Associate Professor, 3Senior Resident
1-3
Department of Obstetrics and Gynaecology, Bharati
Vidyapeeth Deemed University Medical College; Bharati
Hospital & Research Centre, Pune, Maharashtra, India
Corresponding Author: Aniket Kakade, Associate Professor
Department of Obstetrics and Gynaecology, Bharati Vidyapeeth
Deemed University Medical College; Bharati Hospital & Research
Centre, Pune, Maharashtra, India, Phone: 020-45555555, ext-623
e-mail: anikeeet@yahoo.co.in
Journal of South Asian Federation of Obstetrics and Gynaecology, April-June 2017;9(2):141-142
intact cervical stitch was seen, knot was anterior with
Prolene no. 1. The cervix appeared short on per vaginal
examination. On careful history, the patient denied any
removal of the cervical stitch after the previous cesarean
section. She did not have any vaginal infection or dys-
pareunia in the interpregnancy interval. She was using
barrier contraception and did not have any postpartum
visits to the hospital.
Ultrasonography revealed the cervical length to be
3 cm and internal os was closed. The patient was
explained about the persistent forgotten cervical stitch.
In view of the present cervical changes, an informed
decision was taken to keep the stitch in situ. All risks and
complications were explained to the patient. The need
of elective cesarean was explained in view of expected
cervical fibrosis due to persistent cervical stitch.
Pregnancy continued till 37 weeks when patient
developed premature rupture of membranes. On exami-
nation, the fetal heart sounds were normal and cervix
was 1 cm dilated. Membranes were absent. The cervi-
cal stitch was removed. There was dense fibrosis of the
cervix with a very poor Bishops score. Cesarean section
was performed; female baby was 2.4 kg; patient had no
complications and was discharged on day 7.
DISCUSSION
Cervical cerclage remains a commonly performed pro-
phylactic intervention used by most obstetricians, despite
the absence of a well-defined population for whom there
is clear evidence of benefit. The incidence of clinical cervi-
cal cerclage based on the clinical findings is on the rise,
and overall incidence in our tertiary care referral center
is 3 to 5% of live births.
A transvaginal cervical cerclage stitch should be
removed before labor, usually between 36 and 37 weeks
of gestation, unless delivery by elective cesarean section,
in which case suture removal could be delayed until this
time.1
In the absence of preterm labor, elective removal at
36 to 37 weeks of gestation is advisable owing to the
potential risk of cervical injury in labor and the minimal
risk to a neonate born at this gestation.1
We present a very rare case in which the transvaginal
cervical cerclage stitch of the first pregnancy was not
removed and the stitch was detected in the subsequent
141
Aniket Kakade et al
pregnancy. The stitch was left in situ for the present preg-
nancy in view of cervical length of 3 cm on ultrasound
and a clinically short cervix. The persistent stitch was
diagnosed during the booking visit as performing per
speculum and per vaginal examination is a protocol in
our institute. Dense cervical fibrosis was a result of the
persistent suture and hence, a repeat cesarean section
was performed.
The patient did not complain any dyspareunia nor
vaginal infection during the interpregnancy interval. The
cervical stitch did not cause any ascending infection nor
did it lead to infertility or any menstrual disturbances due
to mechanical blockage of the cervical canal. There was
no cervical erosion found on examination.
A general practice in rural areas and some urban
population is to remove the stitch at the time of elective
cesarean section under anesthesia. The timing is usually
after the surgery is over, just after vaginal toileting. Hence,
there is a theoretical risk of forgetting to remove the suture.
We recommend a practice of elective removal of cer-
vical cerclage suture in the outpatient department and
showing the removed suture to the patient. If the suture
is removed in the operation theater, then the stitch is
142
shown to the patient in the recovery room. The practice
of performing per speculum and per vaginal examination
during booking visits is also encouraged to help diagnose
such untoward incidents.
This reported case also enhances the fact that cervical
cerclage increases the incidence of cervical fibrosis.
Several adverse outcomes have been reported in
patients receiving cerclage including preterm prema-
ture rupture of membranes, infectious complications,
postpartum endometritis, increased uterine contractions
requiring tocolysis, and cesarean delivery secondary to
cervical stenosis.2
Most obstetricians suggest removal of cerclage
electively once a gestational age of approximately 36 to
38 weeks is achieved.
REFERENCES
1. Royal College of Obstetricians and Gynaecologists. Green-top
Guideline No. 60 Cervical Cerclage, May 2011. p. 1-21.
2. Odibo AO, Farrell C, Macones GA, Berghella V. Develop-
ment of a scoring system for predicting the risk of preterm
birth in women receiving cervical cerclage. J Perinatol 2003
Dec;23(8):664-667.